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Self-management interventions promote illness management among adults with chronic health conditions. Little is known regarding the processes by which these interventions have their effects. The present study examined how Living Well, an effective self-management intervention for adults with serious mental illness, led to health behavior change in a randomized controlled trial. A convenience subset ( N = 15) of participants completed qualitative interviews regarding the feasibility/acceptability of Living Well. An inductive secondary qualitative analysis, using a combination of interpretive phenomenological and social constructivist approaches, was conducted to examine processes of change. Results indicate that Living Well provided information and knowledge, opportunities for learning from others and real-world practice, and an interpersonally supportive environment. These active ingredients led to enhanced self-awareness, confidence, sense of control, and behavior and health status changes among participants. These findings are considered in the context of prominent behavior change theories such as social cognitive theory and self-regulation.

Ending Self-Stigma is a nine-session group intervention designed to teach individuals experiencing mental illness a set of tools and strategies to effectively deal with self-stigma and its effects. The authors examined the efficacy of Ending Self-Stigma with an active comparison group focused on general health and wellness education (the Health and Wellness intervention) in a cohort of veterans.Veterans with serious mental illness (N=248) were randomly assigned to either the Ending Self-Stigma or the Health and Wellness intervention. Participants completed assessments of symptoms, internalized stigma, recovery, sense of belonging, and other aspects of psychosocial functioning at baseline, posttreatment, and 6-month follow-up. Repeated-measures, mixed-effects models were used to examine the effects of group × time interactions on outcomes.Individuals in both groups experienced significant but modest reductions in self-stigma and increases in psychological sense of belonging after the treatments. The Ending Self-Stigma and Health and Wellness interventions did not significantly differ in primary (self-stigma) or secondary (self-efficacy, sense of belonging, or recovery) outcomes at posttreatment. Significant psychotic symptoms moderated treatment effects on self-stigma, such that among individuals with significant psychotic symptoms at baseline, those who participated in Ending Self-Stigma had a significantly greater reduction in internalized stigma than those in the Health and Wellness intervention.Interventions directly targeting self-stigma and those that may address it more indirectly may be helpful in reducing internalized stigma. Individuals experiencing psychotic symptoms may be more likely to benefit from interventions that specifically target self-stigma.

Peer specialists, or individuals with lived experience of mental health conditions who support the mental health recovery of others, often work side-by-side with traditional providers (non-peers) in the delivery of treatment groups. The present study aimed to examine group participant and peer provider experiences with peer and non-peer group co-facilitation. Data from a randomized controlled trial of Living Well, a peer and non-peer co-facilitated intervention for medical illness management for adults with serious mental illness, were utilized. A subset of Living Well participants (n = 16) and all peer facilitators (n = 3) completed qualitative interviews. Transcripts were coded and analyzed using a general inductive approach and thematic analysis. The complementary perspectives of the facilitators, teamwork between them, skillful group pacing, and peer facilitator self-disclosure contributed to a warm, respectful, and interactive group atmosphere, which created an environment conducive to social learning. Guidelines for successful co-facilitation emerging from this work are described.

Insomnia is a prevalent experience for individuals with serious mental illness, and is one of the most common reasons for mental health referrals in the Veterans Health Administration. Insomnia also critically impacts psychiatric, cognitive and somatic outcomes. However, there is limited information about how people with serious mental illness (i.e. schizophrenia spectrum, bipolar, or major depressive disorders, with serious functional impairments) understand and respond to problems with their own sleep. Bringing this information to light will yield novel methods of research and treatment. The purpose of this study was to examine reactions to insomnia among veterans with serious mental illness and insomnia. An inductive phenomenological approach was used to collect data from 20 veterans with serious mental illness and insomnia using semi-structured interviews. Six themes were identified: Becoming Aware that Insomnia is a Problem; Response to and Dissatisfaction with Medications; Strategies to Get Better Sleep: Contrary to Usual Guidelines; Personal Responsibility for Getting Sleep; Resigned and Giving Up; and Acceptance and Persistence. These results provide insight into the process of identifying insomnia and the subsequent cognitive and behavioural responses that are used to manage sleep disturbances among veterans with serious mental illness, a group often excluded from gold-standard treatments for chronic insomnia. Clinical implications and recommendations for improving treatment efficacy are discussed.

Background Emerging adults with early psychosis demonstrate high rates of service disengagement from critical early intervention services. Decision support interventions and peer support have both been shown to enhance service engagement but are understudied in this population. The purposes of this article are to describe the development of a novel peer-delivered decision coaching intervention for this population and to report plans for a pilot study designed to gather preliminary data about its feasibility, acceptability, and potential impact. Methods The intervention was developed based on formative qualitative data and in collaboration with a diverse team of researchers, key stakeholders, and expert consultants. The pilot trial will utilize a single-group (N = 20), pre-post, convergent mixed-methods design to explore whether and how the intervention addresses decision-making needs (the primary intervention target). The impact of the intervention on secondary outcomes (e.g., engagement in the program) will also be assessed. Additionally, through observation and feedback from the peer decision coach and study participants, we will evaluate the feasibility of research and intervention procedures, and the acceptability of information and support from the peer decision coach. Discussion The peer-delivered decision coaching intervention holds promise for assisting young people with making informed and values-consistent decisions about their care, and potentially enhancing service engagement within this traditionally difficult-to-engage population. If the intervention demonstrates feasibility and acceptability, and pilot data show its potential for improving treatment decision-making, our work will also lay the foundation for a new evidence base regarding roles for peer specialists on early intervention teams. Trial registration This trial was registered with ClinicalTrials.gov (Identifier: NCT04532034) on 28 August 2020 as Temple University Protocol Record 261047, Facilitating Engagement in Evidence-Based Treatment for Early Psychosis.

Experiencing psychosis-spectrum symptoms is challenging to youth. Among many difficulties, internalized mental health stigma-the internalization of negative stereotypes-can lead to shame and withdrawal. The objective of this study was to better understand the correlates of internalized stigma among a clinical sample of youth with psychosis-spectrum symptoms. Participants (n = 66; 12-25 years old) were referred by community providers in Maryland, United States. Psychosis-spectrum symptoms were measured via the Structured Interview for Psychosis-Risk Syndromes (SIPS); family-functioning was measured via the Family Assessment Device. Interviewers rated participants' social/role functioning via the Global Functioning: Social and Role Scales. Internalized stigma was measured using the Internalized Stigma of Mental Illness (ISMI) total scale and subscales. The sample included 34 individuals at clinical high risk for psychosis, 16 experiencing early psychosis, and 16 help-seeking controls. Regression analyses indicated that unusual beliefs, avolition, role functioning, and lower family-functioning (caregiver-reported) were significantly associated with higher aspects of internalized stigma, controlling for other symptoms and sociodemographics. These models explained 27% of the variance (adjusted R2) in the total ISMI scale and between 15% to 49% of the variance in ISMI-subscales. Among this help-seeking sample, unusual beliefs, avolition, higher role functioning, and lower family-functioning (caregiver-reported) were associated with more internalized stigma. Pending future research with larger samples, therapeutic interventions focused on these factors and their correlates may benefit youth. Future research is needed to determine temporal precedence of these associations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

AIM: Many emerging adults disengage from early intervention in psychosis (EIP) services prematurely. Service disengagement may be in part due to having unresolved treatment decision-making needs about use of mental health services. A basic understanding of the decision-making needs of this population is lacking. The purpose of this qualitative study was to identify the range of treatment decisions that emerging adults face during their initial engagement in an EIP program and elucidate barriers and facilitators to decision-making. METHODS: Twenty emerging adults with early psychosis were administered semi-structured interviews to capture treatment decision-making experiences during the first six months after enrollment in an EIP program. Interviews were audio-recorded and transcribed verbatim. Responses were independently coded by two authors using an integrated thematic analysis approach; differences in coding were discussed to consensus. Data analysis was facilitated using NVivo 12 Plus. RESULTS: Emerging adults identified numerous decisions faced after EIP enrollment. Decisions pertaining to life and treatment goals and to starting and continuing psychiatric medication were commonly selected as the most difficult/complicated. Decision-making barriers included not having the right amount or type of information/knowledge; social factors (e.g., lacking social support, opposition/pressure); lacking internal resources (e.g., cognitive and communication skills, self-efficacy, motivation); and unappealing options. Obtaining information/knowledge, social supports (e.g., connection/trust, learning from others’ experiences, encouragement), considering personal values, and time were decision-making facilitators. CONCLUSIONS: This study informs development and optimization of interventions to support decision-making among emerging adults with early psychosis, which may promote service engagement.

One prominent social-cognitive model of internalized stigma by Corrigan and his colleagues (2012; 2002) proposes that individuals are exposed to societal stereotypes about mental illness, at least tacitly agree with them, and may apply them to oneself, engendering harmful self-beliefs. There is limited empirical support for this model in serious mental illness. Moreover, it is not clearly established how internalized stigma and its associated factors impact recovery in this population. The current study uses structural equation modeling (SEM) to assess the social-cognitive model's goodness of fit in a sample of Veterans with serious mental illness (Veteran sample, n = 248), and then validates the model in a second and independent sample of individuals receiving community-based psychiatric rehabilitation services (community sample, n = 267). Participants completed the Self-Stigma of Mental Illness Scale (SSMIS; Corrigan et al., 2006) and measures of self-esteem, self-efficacy, and recovery attitudes. Consistent with Corrigan and colleagues' formulation of internalized stigma, SEM analyses showed a significant indirect pathway from stereotype awareness, to stereotype agreement, to application to self, to self-esteem decrement, to poorer recovery attitudes. Additionally, there was a significant direct effect from stereotype awareness to self-esteem. This study shows that individuals with serious mental illness experience psychological harm from stigma in two ways: (1) through perceived public prejudice and bias, and (2) through internalizing these negative messages. In particular, stigma harms individuals' self-esteem, which then reduces their recovery attitudes.

Informed by the Network-Episode Model, 26 African-American men with serious mental illness and 26 members of their kinship networks completed in-depth qualitative interviews about their exp...

Individuals with serious mental illness and veterans are two populations at elevated risk for suicide; however, research has not examined whether veterans with serious mental illness may be at higher suicide risk than nonveterans with serious mental illness. Additionally, overlapping risk factors for suicide in these populations may account for differences in suicide-related outcomes between these groups. Therefore, the aim of this study was to identify differences in death ideation and suicide ideation among veterans and nonveterans with serious mental illness. We also aimed to explore these effects after adjusting for potentially shared risk factors. We found that veterans with serious mental illness reported death ideation and suicide ideation more than twice as often as nonveterans with serious mental illness. After adjusting for demographic, psychiatric, and theory-driven risk factors, the effect of veteran status on death ideation remained significant, though the effect on suicide ideation was no longer significant. Depressive and psychotic symptoms were significant predictors of death ideation; depressive symptoms and hostility were significant predictors of suicide ideation. Clinicians should particularly monitor death ideation and suicide ideation in veterans with serious mental illness, as well as associated clinical risk factors such as depression, psychotic symptoms, and hostility. (PsycINFO Database Record

Background Current research has found that higher rates of person-centered care (PCC) are associated with greater treatment adherence and positive treatment outcomes. However, the instruments used to access PCC primarily collect data on provider behavior, rather than consumer participation in PCC, despite the necessary co-equal and collaborative nature of PCC interactions. Objectives The objective of the current study was to test the hypotheses that: (1) the Perceived Involvement in Care Scale (PICS) consumer information subscale and the consumer decision making subscale are not correlated with the PPPC subscales and, (2) consumer perceptions of person-centeredness and of consumer involvement in care are significant independent explanatory variables for the theoretically or quantitatively grounded outcomes of therapeutic alliance, treatment adherence, and mental health care system mistrust. Methods Cross-sectional survey data was collected from 82 mental health care consumers receiving services at two Veterans Health Administration (VHA) facilities. Participants completed surveys on perceptions of PCC, consumer involvement in care, therapeutic alliance, medication adherence, and mental health care system mistrust. Results Significant correlation between the consumer participation and PCC subscales was mixed. Higher levels of PCC were associated with greater therapeutic alliance, less suspicion of mental health care systems, less perception of lack of support from providers, and less beliefs about group disparities in care. Consumer involvement was only significantly related to suspicion of mental health care systems. Discussion and conclusions These findings may be a function of the locus of each outcome variable. When conducting PCC research investigators should consider how the outcomes they are examining inform the method through which they measure patient-centeredness.

Background The onset of psychosis-spectrum symptoms may be challenging to young people who are developing their identity. Internalized mental health stigma--the internalization of negative mental illness stereotypes (e.g., believing stereotypes to be true and applying them to yourself)--can lead to secrecy, shame, and withdrawal. Family factors can impact individuals who are experiencing early psychosis, but more work is needed to understand the relationship between family factors and stigma. One objective of this study was to examine if there were differences in internalized stigma across diagnostic groups. Another objective of this study was to better understand the predictors of internalized stigma among youth, particularly understudied aspects of youth stigma such as family functioning and specific types of psychosis-spectrum symptoms (e.g., positive symptoms). Methods Participants aged 12–25 (N = 68; Mean age = 16.41, SD = 2.88) were recruited from community providers, clinics, hospitals, and schools in Maryland, USA. Participants were classified as meeting criteria for clinical high risk for psychosis (51%), early psychosis (24%), or help-seeking controls (25%). The sample was predominantly White (53%), followed by Black/African-American (19%), Biracial/Multiracial (18%), and Asian (10%). Psychosis-spectrum symptoms and depressive symptoms were measured via the clinician-administered Structured Interview for Psychosis-Risk Syndromes (SIPS) and family functioning (e.g., cohesion, support) was measured via the self-reported Family Assessment Device. Internalized stigma was measured using the self-reported Internalized Stigma of Mental Illness (ISMI) scale. ANOVA was used to test for differences in internalized stigma between high risk, early psychosis, and help-seeking controls. Multiple regression was used to evaluate predictors of internalized stigma. Results Initial analyses indicated that there were no significant differences between the three diagnostic groups (F = 1.50, p = .23), but that clinical high risk for psychosis participants had the highest endorsement of internalized stigma (η2 = .05). Regression analyses indicated that unusual thought content/delusional ideas (one type of psychosis-spectrum positive symptom experiences measured by the SIPS), depressive symptoms, and lower family functioning significantly predicted (p < .05) higher internalized stigma, controlling for other psychosis-spectrum positive symptom experiences. These variables explained 26% of the variance in ISMI in the model (F = 4.01, p = .001). Negative, disorganized, and general SIPS items (except depression), as well as age, gender, race/ethnicity, relationship status, family history of psychosis, and income level, were unrelated to ISMI. Discussion This is the first study to assess the relationship between family functioning, psychosis-spectrum symptoms, and internalized stigma among youth. Youth endorsement of unusual thought content/delusional ideas, depressed mood, and lower family functioning were associated with more self-reported internalized stigma from mental health concerns. Better understanding the predictors of internalized stigma among youth can lead to more tailored and effective treatment approaches. This study suggests that a particular focus on certain positive symptoms and family functioning may be warranted in the treatment of internalized stigma. Future research is needed to determine the temporal precedence and nature of the impact of these factors on ISMI, in addition to the potential differential impact of family factors by race/ethnicity and culture.

Experiences of and concerns about encountering stigma are common among veterans with posttraumatic stress disorder (PTSD). One common and serious consequence is self-stigma, which is when an individual comes to believe that common negative stereotypes and assumptions about PTSD are true of oneself. The current study was a pilot randomized trial that evaluated the feasibility, acceptability, and preliminary outcomes of the Ending Self-Stigma for PTSD (ESS-P) program, a nine-session group intervention that aims to assist veterans with PTSD learn tools and strategies to address stigma and self-stigma. Veterans (N = 57) with a diagnosis of PTSD who were receiving treatment in U.S. Veterans Health Administration outpatient mental health programs were recruited. Participants were randomized to either ESS-P or minimally enhanced treatment as usual and assessed at baseline and after treatment on clinical symptoms, self-stigma, self-efficacy, recovery, and sense of belonging. Information on mental health treatment utilization for the 3 months before and after group treatment was also collected. Compared to controls, there was a significant decrease in self-stigma, d = -0.77, and symptoms of depression, d = -0.76, along with significant increases in general and social self-efficacy, ds = 0.73 and 0.60, respectively, and psychological experience of belonging, d = 0.46, among ESS-P participants. There were no differences regarding recovery status or changes in treatment utilization. The results of the pilot study suggest that participation in ESS-P may help reduce self-stigma and improve self-efficacy and a sense of belonging in veterans with PTSD.

Objective There is emerging evidence that internalized stigma increases risk for suicide among individuals with serious mental illness. The purpose of the current study was to evaluate whether sense of belonging moderates the relationship between internalized stigma and suicidal ideation. Method Two hundred forty-two veterans with serious mental illness completed measures of internalized stigma, belongingness, and depression. Moderation analysis was used to determine whether sense of belonging interacts with internalized stigma to predict suicidal ideation when accounting for individual differences in depression and relevant demographic variables. Results Consistent with our hypothesis, sense of belonging significantly moderated the relationship between internalized stigma and suicidal ideation. Specifically, the relationship between internalized stigma and suicidal ideation was strongest when sense of belonging was low. Conclusions and implications for practice Internalized stigma and belongingness interact to increase risk for suicide. Both constructs should be assessed and included in interventions to reduce suicide risk among veterans with serious mental illness. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background Chronic pain is highly prevalent among individuals with mood disorders. While much is known about the relationship between pain and unipolar depression, little is known about pain experiences among people with bipolar disorder. This pilot study addresses this gap by examining pain and its relationship to mood and functioning in a sample of US military veterans with bipolar disorder. Methods Qualitative interviews were conducted with 15 veterans with bipolar disorder and chronic pain who were recruited from outpatient services within a Veterans Affairs medical center. Results Veterans reported a bidirectional relationship between pain and bipolar depression. When discussing manic episodes, individuals’ experiences varied between notable reductions in pain (usually in euphoric states), increases in pain (usually in angry/irritable states), and feeling disconnected from pain. Many reported that increased activity when manic contributed to worse pain after an episode. Veterans clearly articulated how these connections negatively affected their functioning and quality of life. Limitations This was a small, retrospective study that included a non-random sample of veteran participants from one VA medical center. All veterans were engaged in outpatient mental health care, so the majority reported that their mood has been well-stabilized through medications and/or psychotherapy. Conclusions Chronic pain experiences appear to be related to depressive and manic mood states and significantly affects functioning and quality of life in Veterans with bipolar disorder. This study highlights the need to assess chronic pain among veterans with bipolar disorder, as changes in mood could have significant implications for functioning and pain management.

Objective The negative impacts of stigma on mental health treatment initiation are well established, but the relationship of stigma to proactive engagement in mental health treatment (e.g., actively working toward therapy goals) is largely unexamined. This study examined the relationship between mental health treatment engagement and stigma experiences, discrimination experiences, and internalized stigma among adults with serious mental illness. Age, race, gender, and education were tested as moderators of the relationships between stigma-related variables and treatment engagement. Method Data were collected from 167 adults with serious mental illnesses who were receiving services at 5 psychosocial rehabilitation programs. Treatment engagement was assessed by participants' primary mental health care providers, using the Service Engagement Scale. The relationship between treatment engagement, stigma, and discrimination as well as potential demographic moderators were tested with Pearson's correlations and multiple linear regressions. Results Treatment engagement was not correlated with experiences of stigma, experiences of discrimination, or application of stigmatizing beliefs to self. Gender, race, and age were not significant moderators but education was. Experiences of stigma were associated with greater treatment engagement in those with a higher level of education (p = .007), whereas application of stigma to one's self was associated with poorer treatment engagement in those with a higher level of education (p = .005). Conclusions and implications for practice Among individuals with higher levels of education, efforts to prevent internalization of public stigma may be crucial to promote proactive mental health treatment. Replication studies are needed to confirm these findings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

OBJECTIVE: Mental illness stigmatization has harmful effects on recovery from serious mental illness (SMI). Experiencing prejudice and discrimination can lead to internalized stigma (i.e. the cognitive and emotional internalization of negative stereotypes and application of those stereotypes to the self). Internalized stigma may lead to decrements in self-esteem and self-efficacy, negatively affecting recovery. However, to date no study has examined the effects of stigma experiences on recovery-related outcomes serially through internalized stigma, self-esteem, and self-efficacy in a single comprehensive model. The present study sought to address this gap. METHODS: During baseline assessments for two randomized controlled trials, adults with SMI (N = 516) completed standardized measures assessing the variables of interest. In a secondary analysis of these data, separate serial mediation models were tested for recovery orientation, perceived quality of life, and social withdrawal as outcomes. Experiences of stigma was entered as the predictor variable, and internalized stigma, self-esteem, and self-efficacy as serial mediators, in that order. Competing models with alternate orders, as well as parallel mediation models, were also tested to evaluate directionality. RESULTS: Our hypothesized serial mediation model was the best fit, though self-efficacy was not found to be a critical mediator. Experiences of stigma led to internalized stigma, which influenced self-esteem, and recovery-related outcomes consistent with the social-cognitive model of internalized stigma. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Internalized stigma is an essential target for intervention. Treatments that omit it as an explicit target and only address downstream effects of stigma experiences (e.g., self-esteem), may not be effective.

OBJECTIVE Voice-hearers tend to face a high degree of stigma that can impact subjective well-being and social functioning. However, researchers have hypothesized that the content of the voice-hearing experience and its cultural context are relevant to stigma responses. This study experimentally tested how perceptions of voice-hearing experiences change as a function of the voice's content and the perceiver's characteristics. METHOD In total, 143 nonclinical participants were presented with vignettes describing people who heard voices that were attributed to either "God" or "Abraham Lincoln" and were described as either complimentary/encouraging or insulting/threatening. For each vignette, participants were asked about the likelihood that the voice-hearer had schizophrenia or mental illness. The Causal Beliefs Questionnaire was also delivered, with two new subscales added to test for belief in positive and negative religious causes for the voices. Stigma was measured by perceived dangerousness and desire for social distance. RESULTS Voice-hearing experiences elicited greater stigma from participants who endorsed greater likelihood that the voice-hearer was mentally ill, greater belief in biological causes of the voice-hearing, negative religious causes, psychosocial causes, socialization causes, and causes related to personal responsibility. Endorsing positive religious causes was associated with lower stigma. Participants who were more religious were more likely to attribute voice-hearing experiences to negative religious causes (possession, lack of/misguided faith), except when the target was described as hearing the voice of God saying positive things. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The stigma of voice-hearing experiences depends upon what the voice is saying and perceptions about the cause of the voice. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

BACKGROUND: Negative symptoms predict poor outcome in schizophrenia yet there is no recommended evidence-based treatment. Enhancing community functioning and promoting recovery in Veterans with schizophrenia is a VHA priority. METHODS: This presentation will review the sample, methods, and preliminary qualitative findings from an in-progress, VA-funded trial to evaluate a behavioral intervention to increase community engagement – Engaging in Community Roles and Experiences (EnCoRE) - in Veterans with schizophrenia who receive mental health services at three VA Medical Centers. EnCoRE includes motivational, cognitive, and behavioral skills training strategies aimed at increasing intrinsic motivation to engage in community activities, reduce negative expectancies, and perform skillfully in social situations. To date, 72 Veterans with schizophrenia have enrolled and 56 have completed study assessments. Participants completed post-assessment qualitative interviews about their experiences in EnCoRE, aspects of the program they perceived as more or less helpful, what they found challenging about becoming more active, and other reflections or suggestions about the intervention. RESULTS: Interviews were analyzed in 3 phases employing constant comparison of data units with others and data with emerging themes and examining meaning across interviews via focused cross-interview coding to organize themes, variations and interrelationships among the ideas, views, and experiences of the sample. We also examined relationships among using different components of the program and reports of engaging in community activities with intervention engagement and attendance. Participants who attended more frequently reported greater use of EnCoRE skills and strategies to increase participation in community/family activities. Participants reported benefits of specific components – especially detailed Action Planning - and offered suggestions for improvement. Participants reported that the group format, in which they felt that they were accountable to other Veterans, helped them feel more motivated to accomplish the goals they set in each group meeting. CONCLUSIONS: Veterans with schizophrenia are receptive to a behavioral program to improve community functioning. Features such as focused content with in-depth planning for implementation, small group size, and having other Veterans to help and learn from can help Veterans with schizophrenia participate in new community activities. [Source of funding: VA RR&D (Bennett, PI)]

Consumers with serious mental illness (SMI) frequently disengage from treatment; tools to enhance rapport and therapeutic alliance with these consumers are needed. The Cultural Formulation Interview (CFI), published in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), assesses social and cultural context as it relates to mental health and has potential as a rapport-building tool. The present study aimed to examine the perspectives of consumers with psychotic spectrum disorders on participating in the CFI. Consumers (N = 14) with psychotic disorders were recruited from mental health programs at an urban Veterans Affairs Medical Center. They participated in the CFI followed by a debriefing interview, during which they were queried about their experiences with the CFI. Debriefing interviews were audio recorded and transcribed. Thematic analysis was used to collate the data and identify themes. Participants reported that the CFI was validating, therapeutic, and led to deeper realizations about themselves and their recovery. The CFI may be used to simultaneously enhance rapport and obtain meaningful health narrative data with consumers with psychotic disorders. The CFI may be a valuable tool to promote treatment engagement among individuals with SMI.

Background Family members of individuals with early psychosis (EP) play critical roles in their engagement with EP services, but family member experiences of those roles are insufficiently understood. Methods We conducted semi-structured interviews with 18 family members of individuals enrolled in EP services during the Recovery After an Initial Schizophrenia Episode-Implementation Evaluation Study (RAISE-IES study), to better understand their experiences engaging with EP specialty care and their roles in client engagement in services. Results Family members described diverse experiences with the interplay among distress regarding their loved one's illness, uncertainty engaging with programme staff and highly valued facets of the clinical programme. These included ongoing family outreach and support, frequent communication from staff, programme flexibility and individualization of care. They also described varied and stressful complexities involved in providing practical assistance and encouragement to support their loved one's engagement in care. Competing responsibilities, time and resource limitations, and the intricacy of providing support while fostering autonomy impacted their roles and experiences. Conclusions Given key family roles for most EP clients, understanding family members’ highly individual experiences and responding to them in tailored ways is necessary to best support families in helping their loved ones engage in care and recovery as well as navigate their own worry and stress. Recommendations for engaging and supporting family members are highlighted.

There is a growing evidence base for the utility of peers in supporting physical health outcomes among aging Veterans with mental illness. This talk will consider two questions: (1) what does it mean to be a “peer” when the focus is improving physical health, and (2) how does peer support promote health behavior change? In considering these questions, select peer-delivered interventions recently or currently being tested in the VA will be discussed. Data from qualitative interviews (N=16; ages 47-75) from a recent RCT of Living Well, a peer co-facilitated group intervention promoting illness self-management, will be presented. These data shed light on the peer role, especially the role of peer self-disclosure in promoting group cohesion, social learning, self-efficacy, and health behavior change. Notably, when physical health is the focus, participants relate to peer providers across diverse characteristics, and not necessarily based on a shared lived experience of mental illness.

Objective More women veterans than men use Veterans Health Administration (VHA) mental health services. Some psychiatric medications are associated with weight gain and other metabolic side effects, with women more susceptible and reporting more distress than men. We sought to explore how women experience and manage medication-induced weight gain to identify strategies for improving its prevention and management in women. Method We completed semistructured, qualitative interviews with 30 female veterans with serious mental illnesses prescribed antipsychotic or mood stabilizer medications and 18 mental health prescribers. Interview transcripts were summarized and coded via principles of phenomenological inquiry to develop themes reflecting the study purpose. Results We identified 5 themes related to females' experiences with medication-induced weight gain. Female veterans described considerable psychological and physical distress associated with weight gain. However, many expressed a willingness to accept weight gain as a trade-off for medications' therapeutic effects, a theme echoed by prescribers. Both described primarily using reactive rather than proactive or preventative weight management approaches and described the limited effectiveness of reactive approaches. Other contributing factors, including the multiple and uncertain causes of weight gain, uneven quality and quantity of weight loss information, lack of social support, and environmental barriers, add to the difficulty and complexity of their struggles. Conclusions and implications for practice These findings improve our understanding of numerous veteran-, prescriber-, and environmental-level factors in the management of medication-associated weight gain in women that may be useful in designing gender-specific interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background Psychosis is one of the most highly stigmatized mental health conditions (Thornicroft et al., 2009). Compared to those with other mental health concerns, people diagnosed with schizophrenia spectrum disorders are more likely to be perceived by others as dangerous, violent, and unpredictable. As a result, they are often socially marginalized and discriminated against (Crisp et al., 2000; Martin et al., 2007). Individuals at clinical high risk (CHR) for psychosis may be at lower risk for experiencing public stigma, given that their symptoms are often less outwardly visible at this early stage of illness. However, evidence suggests that those at CHR experience high levels of self-stigma, as they may internalize negative stereotypes related to psychosis (Yang et al., 2010; Yang et al., 2015). Internalized stigma can negatively impact help-seeking behavior and has been associated with lower self-esteem and the underreporting of mental health symptoms (Corrigan, 2004; Corrigan, 2007; Saporito, Ryan, & Teachman, 2011; Rüsch, Angermeyer, & Corrigan, 2005). Despite these findings, no studies to-date have examined how internalized stigma may impact reporting of attenuated psychosis symptoms in the CHR population. The current study aims to examine whether discrepancies between self-report and clinician-rated measures of psychosis risk are associated with internalized stigma in a sample of help-seeking adolescents and young adults. We hypothesized that higher levels of self-stigma will predict inconsistencies between self-reported symptom severity and clinician-obtained diagnoses of psychosis risk. Methods Participants will include youth classified as either non-psychosis-related help-seeking controls or at clinical high risk (CHR) for psychosis, as determined by the Structured Interview for Psychosis-Risk Syndromes (SIPS; Miller et al., 2003). The SIPS is administered by trained raters and is currently considered the gold standard tool for diagnosing clinical high-risk syndromes (Thompson et al., 2018). In addition to SIPS diagnoses, psychosis risk will also be assessed using the Prime Screen – Revised (PS-R; Miller et al., 2004), a brief, 12-item self-report questionnaire designed to measure attenuated positive symptoms. Lastly, internalized stigma will be assessed using the Internalized Stigma of Mental Illness Inventory (ISMI; Ritsher, Otilingam, & Grajales, 2003), a 29-item self-report questionnaire designed to measure subjective experiences of stigma in adolescents (e.g., endorsement of negative stereotypes, social withdrawal and feelings of alienation due to mental health problems, etc.). Results Preliminary analyses demonstrate a significant interaction between Prime scores and internalized stigma in predicting SIPS diagnoses. Specifically, higher scores on the Prime were associated with increased odds of being diagnosed as CHR on the SIPS, but only for those participants who endorsed low and mean levels of stigma. For participants who endorsed high levels of stigma, there did not appear to be any relation between Prime scores and SIPS diagnoses. Discussion At the time of submission, participant recruitment is ongoing, and results and discussion will be presented on the final sample. Findings may inform efforts to improve detection and accurate diagnosis of psychosis risk syndromes in individuals at early stages of illness.

Older Veterans with psychotic disorders experience high rates of life-threatening medical conditions and persistent cognitive, psychiatric, and social impairment which contributes to risk for early institutionalization. Supervised fitness training, in which participants complete a set of recommended exercises under the supervision of exercise physiologists in a gym facility, decreases risk for functional decline among older Veterans. The present study describes the development of a coaching intervention, delivered by VA Peer Specialists (Veterans with a lived experience of mental illness), to promote participation in supervised fitness training among older Veterans with psychotic disorders. Four focus groups were conducted with a panel of older Veterans with mental illness to inform the intervention; the following themes emerged: “Encouragement plus accountability,” “Power in numbers”, “Finding internal motivation in each person,” “Exercise to stay sane,” and “Making exercise part of daily life.” Information from panel discussions was iteratively integrated to inform intervention structure/content.

Peer support is an important component of services for persons with psychiatric illness but the experience of peer mentors is not well understood. This study explored the experiences of peer mentors, all former smokers and persons with psychiatric illness, who provided smoking cessation counseling as part of a 6 month professionally-led intervention. Data was obtained from 383 contact log entries and in-depth interviews with eight peer mentors. Qualitative analysis indicated that mentor roles were unexpectedly varied beyond the focus on smoking cessation. Of the two aspects of "peer-ness," shared smoking history was more prominent, while the shared experience of psychiatric illness was sometimes overlooked. Peer mentors experienced multiple challenges trying to help participants to change their smoking behaviors. Nonetheless, they described their experience as personally rewarding. Future interventions may be improved by anticipating peer mentor role complexity and the inherent tension between providing person-centered support and promoting behavior change.

Family members of consumers with mental illness often play important roles in initiating and supporting treatment. Self-help programs such as the National Alliance on Mental Illness (NAMI) Family-to-Family Education Program (FTF) have been shown to provide a variety of benefits for family members. Despite recognizing the benefits of FTF, little is known about who may benefit most, and in what ways they might benefit. One group of interest is family members of younger consumers, a group shown to report more negative caregiving experiences and more depression and anxiety than caregivers of older consumers. The current study assesses whether relatives of youth (ages 8–18) differ in their response to FTF as opposed to relatives of adults (19 years and older). Results suggest that all members benefit from FTF. Family members of youth in FTF, however, reported gains more pronounced on their depressive symptoms, and negative perceptions and experiences, relative to family members of adults. The importance of peer support programs is discussed, as well as the specific usefulness of these programs to effectively address concerns of relatives of youth with serious mental health concerns.

Objective:This study assessed factors that facilitated or impeded clients’ engagement in services offered by the Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program for youths and young adults experiencing early psychosis. It was part of the larger RAISE Implementation and Engagement Study.Methods:Thematic qualitative analyses of data from in-person, semistructured interviews with 32 clients were used to examine experiences of program services, staff practices, clients’ engagement behaviors, and related factors, such as expectations, family involvement, illness, and setting. Eighteen clients were well engaged with services, and 14 were not. Thirteen were interviewed early in their program involvement (two to nine months after enrollment) and 18 others later (12 to 24 months after enrollment).Results:Four domains of factors influenced engagement: individualized care, program attributes, family member engagement, and personal attributes. A central factor was the program’s focus on cli...

Mental health distress is common, yet many people lack mental health literacy and skills to help themselves and others. In this qualitative study, we used semi-structured interviews to ask graduates of Mental Health First Aid (MHFA-USA), a mental health promotion program designed to address such needs, about its impact. Interviewees described gaining knowledge, skills and confidence to help someone in distress, empathy for people with mental illness, and developing a sense of responsibility and permission to try to help when needed. They gave varied examples of using MHFA-USA skills with strangers, acquaintances, coworkers, clients and family members, and to help themselves, in a range of situations. We integrate these results into a tentative change process diagram, and speculate on its effects for people in distress and community norms regarding emotional and psychiatric distress. We then discuss the implications for MHFA-USA outcomes research.

Consumers with serious mental illness smoke more and are at higher risk for smoking-related illness. We examined provider and consumer factors influencing the implementation of the evidence-based "5 A's" (ask, advise, assess, assist, arrange) in six community mental health centers in greater Baltimore.Data collected as part of a larger study examining the effectiveness of delivery of the 5 A's at patient visits. First, we examined responses to a survey administered to 49 clinicians on barriers and attitudes toward delivering the 5 A's. Second, we used multilevel models to examine variance between patients (n = 228), patient factors, and variance between their psychiatrists (n = 28) in the delivery of the 5 A's (and first 3 A's).The most strongly endorsed barrier was perceived lack of patient interest in smoking cessation. Psychiatrists and patients both accounted for significant variance in the delivery of the 5 A's and 3 A's. Patient "readiness to change" predicted delivery of the full 5 A's, while smoking severity predicted delivery of the first 3 A's.There is a critical need for creative and collaborative solutions, policies, and clinician training to address actual and perceived obstacles to the delivery of evidence-based smoking cessation treatment in the mental health care setting.

Objective The social-cognitive model is useful in understanding internalized stigma, but research has not examined it in relationship to recovery orientation, an important outcome. This study examined the impact of the four stages of internalized stigma on recovery orientation and assessed cognitive insight as a moderator. Method Data from a community sample of adults with serious mental illness (N = 268) were collected through structured interviews. Regression-based analyses were used to examine the main effects of internalized stigma on recovery orientation and the moderating effect of cognitive insight. Results Applying stigmatizing beliefs to oneself and the related decrement in self-esteem each predicted decreased recovery orientation. Cognitive insight moderated the effect of self-application of stigmatizing beliefs on recovery orientation. Implications Increasing cognitive insight by fostering flexibility in self-cognitions may help reduce internalized stigma. Interventions may also benefit from addressing the emotional component of internalized stigma, such as feelings of shame. (PsycINFO Database Record

Comments on the original article by Silver and Nemec (see record 2016-43088-001) regarding the recent special issue on peer-delivered services. Silver and Nemec thoughtfully raised important topics for further explanation. Especially intriguing was their commentary on what constitutes "essential peerness"; that is, what qualities or experiences are necessary/sufficient to make a peer a peer? With this editorial, the authors add to that conversation, specifically with regard to the role of peer specialists in health/wellness interventions. (PsycINFO Database Record

Families play an important role in the lives of individuals with mental illness. Coping with the strain of shifting roles and multiple challenges of caregiving can have a huge impact. Limited information exists regarding race-related differences in families' caregiving experiences, their abilities to cope with the mental illness of a loved one, or their interactions with mental health service systems. This study examined race-related differences in the experiences of adults seeking to participate in the National Alliance on Mental Illness Family-to-Family Education Program due to mental illness of a loved one. Participants were 293 White and 107 African American family members who completed measures of problem- and emotion-focused coping, knowledge about mental illness, subjective illness burden, psychological distress, and family functioning. Multiple regression analyses were used to determine race-related differences. African American caregivers reported higher levels of negative caregiving experiences, less knowledge of mental illness, and higher levels of both problem-solving coping and emotion-focused coping, than White caregivers. Mental health programs serving African American families should consider targeting specific strategies to address caregiving challenges, support their use of existing coping mechanisms and support networks, and increase their knowledge of mental illness.

To distinguish the impact of mental illness stigma from that of other negative caregiving experiences, this study examined the unique relationships between stigma and caregiver/family functioning. Adult relatives (n = 437) of individuals with mental illness completed questionnaires regarding caregiving experiences, distress, empowerment, and family functioning, as part of a larger study. Regression analyses examined the relationship between stigma and caregiver/family variables, while controlling for other negative caregiving experiences. Stigma was uniquely associated with caregiver distress, empowerment, and family functioning. Mental illness stigma is a potent source of distress for families and an important target of family services.

The sociocultural identities that people self-assign or accept influence their interpersonal interactions and decision making. Identity-based interventions attempt to influence individuals by associating healthy behaviors with in-group membership. Outreach and educational efforts aimed at veterans may rely on “typical” veteran identity stereotypes. However, as discussed in this Open Forum, there is evidence that veteran identity is not monolithic but rather fluctuates on the basis of personal characteristics and individual military service experiences. Overall, the impact of veteran identity on veterans’ health behaviors and use of health care is not known and has been understudied. A major limiting factor is the lack of a standardized measure of veteran identity that can assess variations in salience, prominence, and emotional valence.

Background: This trial tested Ending Self Stigma (ESS) a psychoeducational intervention designed to help adults with schizophrenia and other serious mental illnesses reduce their internalization of mental illness stigma and its many harmful effects for psychosocial function, personal cognition, motivation, recovery orientation, and self-beliefs.

This community-based randomized controlled trial was carried out to test the Ending Self-Stigma (ESS) psychoeducational intervention, which is designed to help adults with serious mental illnesses reduce internalization of mental illness stigma and its effects.A total of 268 adults from five different mental health programs in Maryland took part. After baseline interview, consenting participants were randomly assigned to the nine-week ESS intervention or a minimally enhanced treatment-as-usual control condition. Participants were assessed by using symptom, psychosocial functioning, and self-stigma measures at baseline, postintervention, and six-month follow-up. Demographic characteristics were assessed at baseline.Compared with participants in the control condition, ESS group participants showed significant decreases on the stereotype agreement and self-concurrence subscales of the Self Stigma of Mental Illness Scale, significant improvement on the alienation and stigma resistance subscales of the Internalized Stigma Mental Illness measure, and a significant increase in recovery orientation from baseline to postintervention. None of these differences were sustained at six-month follow-up.Results indicate that ESS was useful in helping to reduce key aspects of internalized stigma among individuals with mental illnesses and that advances in the delivery, targeting, and content of the intervention in the field may be warranted to increase its potency.

Youth Mental Health First Aid USA (YMHFA) is a manualized training program designed to educate members of the public on common emotional problems and psychological disorders among youth and to provide trainees with tools anyone can use to assist young people in psychological distress. The present study used a pre versus post design to assess the ability of social service employees to generate appropriate strategies to use in hypothetical situations featuring a young person in distress, before versus after participation in the 8-hr YMHFA training. Trainee responses demonstrated significant overall improvement (M = 1.32, SD = 0.80 pretraining vs. M = 1.87, SD = 1.1 posttraining, t = 6.6, p < .001) by including four of the five central YMHFA strategies significantly more often after training. Increased confidence in, likelihood of, and comfort with helping a young person in emotional distress or crisis were also reported posttraining compared to pretraining (all p ≤ .001). Results suggest that individuals participating in YMHFA training are better informed regarding when to assess for risk of suicide, listen nonjudgmentally, encourage appropriate professional help, and encourage self-help strategies with young people in psychological distress. (PsycINFO Database Record

Black adolescents with mental health problems are less likely than non-Black adolescents with mental health problems to receive treatment, primarily for non-financial reasons including negative perceptions of services and providers, and self-stigma associated with experiencing mental health problems. To better understand these obstacles, 16 adolescents and 11 caregivers, recruited from two K-8th grade elementary-middle schools, participated in four focus groups guided by the unified theory of behavior to explore mental health help-seeking behaviors and perceptions of mental health services. In the focus groups, caregivers acknowledged more positive attitudes about seeking mental health services than adolescents, but both expected the experience of actually doing so to be negative. Adolescents and caregivers also acknowledged social norms that inhibit their mental health help-seeking. Therefore, we conclude that interventions targeting expectancies and social norms might increase the connection of urban, under-resourced Black adolescents and their families to mental health services, and be particularly important given the long-term consequences of untreated mental health problems for this group.

Objective: This study examines 6-month follow-up data from participants in a randomized trial of a peer-driven 12-session family support and education program, called family-to-family (FTF) and offered by the US National Alliance on Mental Illness, to determine whether improvements in distress, family functioning, coping and empowerment were sustained. Method: Individuals randomized to the FTF condition were assessed after program completion and then 3 months later on measures of distress, family functioning, coping, and empowerment. We used a multilevel regression model (sas proc mixed) to test for significant changes over time (baseline, 3 and 9 months). Results: All significant benefits that FTF participants gained between baseline and immediately post-FTF were sustained at 9 months including reduced anxiety, improved family problem-solving, increased positive coping, and increased knowledge. Greater class attendance was associated with larger increases in empowerment and reductions in depression and displeasure with ill relative. Conclusion: Evidence suggests that benefits of the FTF program were sustained for at least 6 months without any additional boosters or supports. Peer-based programs may produce sustained benefits for individuals seeking help in addressing challenges and stresses related to having a family member with a mental illness.

Among potential resources for people with serious mental illnesses (SMI) and their families, professionally delivered family psychoeducation (FPE) is designed to engage, inform, and educate family members, so that they can assist the person with SMI in managing their illness. In this article, we review research regarding FPE outcomes and implementation since 2001, updating the previous review in this journal (McFarlane, Dixon, Lukens, & Lucksted, Journal of Marital and Family Therapy 2003; 29, 223). Research on a range of FPE variations continues to return mostly positive effects for adults with schizophrenia and increasingly, bipolar disorder. More recent studies include functional outcomes as well as the more common relapse and hospitalization. FPE research involving adults with other diagnoses is increasing, as is FPE research outside the United States In both cases, uneven methodologies and multiple FPE variations make drawing conclusions difficult, although the core utility of access to information, skill building, problem solving, and social support often shines though. Since the previous review, several FPE programs for parents of children or youth with mood disorders have also been developed, with limited research showing more positive than null results. Similarly, we review the developing inquiry into early intervention and FPE, short-form FPE, and cost studies involving FPE. The second half of the article updates the paradox of FPE's evidence base versus its persistently low use, via recent implementation efforts. Multiple challenges and facilitating factors across healthcare systems and financing, individual programs and providers, family members, and consumers shape this issue, and we conclude with discussion of the need for empirical evaluation of implementation strategies and models.

Objective: The Family-to-Family Education Program (FTF) is a 12-week course offered by the National Alliance on Mental Illness (NAMI) for family members of adults with mental illness. This study evaluated the course’s effectiveness. Methods: A total of 318 consenting participants in five Maryland counties were randomly assigned to take FTF immediately or to wait at least three months for the next available class with free use of any other NAMI supports or community or professional supports. Participants were interviewed at study enrollment and three months later (at course termination) regarding problem- and emotion-focused coping, subjective illness burden, and distress. A linear mixed-effects multilevel regression model tested for significant changes over time between intervention conditions. Results: FTF participants had significantly greater improvements in problem-focused coping as measured by empowerment and illness knowledge. Exploratory analyses revealed that FTF participants had significantly enhanced emotion-focused coping as measured by increased acceptance of their family member’s illness, as well as reduced distress and improved problem solving. Subjective illness burden did not differ between groups. Conclusions: This study provides evidence that FTF is effective for enhancing coping and empowerment of families of persons with mental illness, although not for reducing subjective burden. Other benefits for problem solving and reducing distress are suggested but require replication. (Psychiatric Services 62:591–597, 2011)